| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $5 | $5 | $5 |
| Allergy testing insect venoms CPT 95017 • Allergy | $4 | $4 | $5 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $24 | $24 | $24 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $10 | $10 | $10 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $16 | $16 | $16 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $48 | $48 | $48 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,954 | $2,954 | $2,954 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $3,475 | $3,475 | $3,475 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $823 | $823 | $823 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $36 | $36 | $36 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $94 | $94 | $94 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $48 | $48 | $48 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $232 | $232 | $232 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $279 | $279 | $279 |
| Left heart catheterization CPT 93458 • Cardiology | $371 | $371 | $371 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $53 | $53 | $53 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $72 | $72 | $72 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $86 | $86 | $86 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $116 | $116 | $116 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $180 | $180 | $180 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $293 | $293 | $293 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $105 | $105 | $105 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $2 | $2 | $2 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $153 | $153 | $153 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $7 | $7 | $7 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $3 | $3 | $3 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $88 | $88 | $88 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $65 | $65 | $65 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $80 | $80 | $80 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $197 | $197 | $197 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $66 | $66 | $66 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $768 | $768 | $768 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $9,353 | $9,353 | $9,353 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $33 | $33 | $33 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $352 | $1,938 | $3,523 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $427 | $427 | $427 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $237 | $237 | $237 |